Clinical Content & Reimbursement Director

Elevance Health

Director managing clinical content and reimbursement strategy to improve healthcare costs and service at Elevance Health. Collaborating with multiple stakeholders to implement coding and billing guidelines.

Posted 5/17/2026full-timeNorfolk • Florida, Ohio, Virginia • 🇺🇸 United StatesLead💰 $102,960 - $154,440 per yearWebsite

Tech Stack

Tools & technologies

SQL

About the role

Key responsibilities & impact

Leads fee schedule development for specific plan(s) and/or the development and implementation of clinical editing rules
Works with business partners to assist with cost of care claim editing goals
Performs and/or directs complex fee modeling exercises to ensure that projected unit reimbursement changes meet corporate cost targets
Review healthcare policy (Medicaid manuals, fee schedules, CCI, OIG Alerts, LCAs/LCDs, NCDs, Medicare manuals, etc.) for coding and billing guidelines that can be turned into software editing rules
Create billing edits that provide clients with monetary savings and promote coding accuracy
Prepares and presents cost of care data analysis to support the regions cost of care initiatives
Develops and maintains the provider reimbursement strategy that will lower the cost of care, improve service, and reduce administrative expenses
Manages special projects and initiatives

Requirements

What you’ll need

Requires a BS/BA degree in a related field
minimum of 10 years business and professional experience in provider reimbursement and contracting
Nationally recognized coding or billing credential (CCS, CCS-P, CPC, COC, CIC, CPB, RHIA, or RHIT) is strongly preferred
10+ years of claims editing experience with healthcare payers and/or claims editing software vendors are strongly preferred
Commercial and Medicaid experience highly preferred
Inpatient and outpatient coding experience highly preferred
Strong knowledge of billing, coding, revenue cycle, claims adjudication, NCCI editing, and claims payment rules are highly preferred
Ability to interpret and apply claim edit rules, industry coding guidelines, and claims workflow processes preferred
Proven experience researching, analyzing, and resolving coding and payment integrity issues are preferred
Strong analytical and logic skills, including root-cause analysis and translating policy edits into decision-making logic paths are preferred
Intermediate Excel skills, including pivot tables, VLOOKUPs, and data manipulation are functions strongly preferred
SQL query-building and data lookup skills are preferred
Master’s degree preferred.

Benefits

Comp & perks

comprehensive benefits package
incentive and recognition programs
equity stock purchase
401k contribution

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

fee schedule developmentclinical editing rulesfee modelingbilling editscost of care data analysisprovider reimbursement strategyclaims editingbillingcodingrevenue cycle

Soft Skills

analytical skillslogic skillsroot-cause analysisresearchinganalyzingresolving issuescommunicationpresentation skillsproject managementcollaboration

Certifications

CCSCCS-PCPCCOCCICCPBRHIARHIT